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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOA11UIN COUNTY PUBLIC HEALTH SERV6..t' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. -� c <br /> Job Address/or APN# 12— J CoU� e,�'7� �'• _ City J Parcel Size/APN# <br /> G y C) l(k s. I (K L . Address D4 fle-a S X 7 S 2v 1 Phone # <br /> Owner's Name fe )►Ou^ <br /> � IBZSCJt'1 S �! �h H Address�I 1poD! /U )( Lic# Phone 31S [/�-�_/�'�oO <br /> Contractor L T� <br /> �D� ?'(O� Grl(c,Gdrz Lic# J�ZZ�� Phone # 6S 7f 2 <br /> Sub Contractor_ Address L/ <br /> TYPE OF WELL/PUMP: ❑ NEW WELL [I REPLACEMENT WELL MONITORING WELL # M W- 7 ❑ OTHER I <br /> [I DESTRUCTION [1 OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL # SOIL BORING <br /> [I INSTALLATION [I WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> [I New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS u� <br /> [I INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION /1 DIA. OF CONDUCTOR CASING <br /> [l DOMESTIC/PRIVATE GRAVEL PACK/SIZE Z I0 TYPE OF CASING/STEEL/PVC P V G DIA. OF WELL CASING 2 Ir <br /> [I PUBLIC/MUNICIPAL [) DRIVEN DEPTH OF GROUT SEAL .301 SPECIFICATION S c4 �lD pv G <br /> (IIRRIGATION/AG [IOTHER GROUT SEAL INSTALLED BY S PELz-P-L-A'"\ GROUT BRAND NAME N e �. <br /> MONITORING GROUT SEAL PUMPED: KYes 0 No CONCRETE PEDESTAL BY DRILLER: [) Yes [) No <br /> APPROX.DEPTH 5 O ( LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "1 <br /> certify that_in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of Califor;nia," Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performance <br /> of the wwhich thYs rmit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br /> MUST CA 24 HO S IN ADVANCE F01-ALL REOUI ED INSPECTIONS AT(209)488.3423. Complete drawing at lower area provided. <br /> Signed X Title Date <br /> DEPARTMENT USE ONLY p Q <br /> Application Accepted By Date o Q'r 2 1 '` � Area4�V // <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> L�l}N/l1l.eLG�2. <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES I FEE INFO AMOUNT REMITTED CHECK$ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />